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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_591_Библиотеки_им_академика_М_И_Перельмана
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Chapter 19
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Endoscopic Breast Reduction andLifting
MarcoAurelioFaria-Correa
Abstract Various situations necessitate distinct approaches to breast reduction and
lifting. Some patients have ideal breast size and good skin tone with minimal sagging or upper pole loss. Others exhibit slight breast asymmetry, content with one
breast size while seeking reduction in the larger breast. They specically request
scarless surgery to achieve their goals, making endoscopic breast reduction and lifting an optimal technique for their needs.
Introduction
There is no one breast reduction and lifting technique that can attend all different
situations. There are patients presenting with their ideal size of breast and good skin
tone with minimal degree of ptosis or only the loss of the upper pole. There are also
patients presenting with small degree of breast asymmetry, informing that they are
happy with the size of the smaller breast, asking for reducing the larger breast, and
requesting for scarless surgery that could help them to achieve their goals.
In 1991, the new concepts regarding skin elasticity were introduced into the eld
of plastic surgery by way of innovative techniques of liposuction and periareolar
breast reduction (Avelar and Juarez-Illouz 1986; Peixoto 1980; Ribeiro 1989).
These new concepts, which concern the capacity of the skin to retract, allowed the
author to investigate the feasibility of applying endoscopic methods to subcutaneous tissue to avoid skin resection. The author began by modifying the miniabdominoplasty technique and techniques for breast reduction and
mastopexy—endoscopy was also used as an aid for ap harvesting and placement
M. A. Faria-Correa (*)
Mount Elizabeth Novena Specialist Centre, Singapore, Singapore
e-mail: drmarco@drmarco.com
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_19
315© The Author(s), under exclusive license to Springer Nature
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Fig. 19.1 Set of
instruments developed by
the author from superior to
inferior: light source
retractors; single and cross
puncture elevators;
transcutaneous suture
set—guide, a modied
Reverdin needle, and a
fondue fork; a modied
needle holder; “screwsuture”; “subcutaneous
tomoscope”
M. A. Faria-Correa
of tissue expanders—and to develop promising research regarding axillary inguinal
lymph node dissections (Faria-Correa 1992).
Video-endoscopic methods have been used in different surgical elds such as
gynecology, orthopedics, and general surgery, where many advantages have been
shown. There is less tissue trauma, lower rate of infection, and minimal scarring
(Verbicaro 1993).
Laparoscopic procedures used pressurized CO2 gas to create a space between the
laparoscope and the tissue to allow visualization. In the subcutaneous tissue, however, pressurized gas is not recommended because of the risk of embolism. To circumvent this risk, the author developed the “subcutaneous tomoscope,” which is an
instrument that transfers into a transparent capsule the space needed for illumination and visualization. The optical cavity functions much the same way as a scuba
diving mask does while serving as a blunt dissector because of its wedge-shaped
capsule (Faria-Correa 1992). Specially designed retractors were developed to
increase the necessary working space in addition to instruments such as special
needle holders and needles (Fig.19.1). All of these instruments were designed to
work through minimal incisions.
With video endoscopy, delicate processes can be performed through minimal
incisions that can be made at strategically placed and remote sites avoiding visible
scars. This is an important goal in the eld of aesthetic surgery where scars are
undesirable and may sometimes compromise the nal aesthetic result.
Material andMethods
Endoscopic versions for mastopexy and breast reduction were rst performed in
November 1992. Since then, the endoscopic technique has been used to treat 220
patients. The patients ranged in age from 14 to 62years old. They presented with
rst- or second-degree ptosis with or without hypertrophy. Patients were selected
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on the basis of having good skin elasticity without signicant excess skin.
Breastfeeding and striae were not considered contraindications as long as the
patient maintained good skin elasticity. Premature moderate ptosis recurrence was
observed when the endoscopic technique was applied to patients presenting with
skin accidity. An important application for this technique is in patients with a
small degree of breast asymmetry, particularly in young patients. The larger breast
can be reduced with no visible scar or loss of sensation to match the smaller, unoperated breast.
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Technique
The traditional video-endoscopic system and the subcutaneous tomoscope, associated with endoscopic instruments, were used to create an optical space. Thus, monitor control could be used without CO2 distension. Some instruments were modied,
and new ones were developed creating a set of instruments that facilitate this procedure. Regular laparoscopic forceps and scissors connected to the electrocautery
were used.
Positioning ofthePatient andtheTeam
Proper positioning of both the patient and the surgical team is important for facilitating this procedure. The monitor is placed over the patient’s head, and the anesthesiologist stays beside the patient’s head. The surgeon works beside the patient. The
surgical table must be adequate to allow change in the patient’s positioning from
supine to sitting.
Planning
In planning the mammoplasty, the breast must be observed as a three-dimensional
structure (Figs.19.2, 19.3, and 19.4). Working endoscopically and considering the
three-dimensional breast volume as a cone, looking upward, the bottom of the cone
can be seen (Fig.19.5). The goal is to work on the base of the glandular cone. The
rst step is to plan the undermining of an enlarged area between the breast and the
pectoralis fascia, thus creating a retromammary pocket. Both gland advancement
(mastopexy) and breast tissue reduction are planned to proceed from the bottom of
the cone. If only mastopexy is needed, the incisions are marked at the inframammary fold. If breast reduction is intended, the incisions must be placed a little above
the fold.
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Fig. 19.2 Video-endoscopic breast reduction and mastopexy technique: A and A’, level point; B′,
upper position; I, retromammary pocket; II, tissue resection area; III, submammary sulcus incision; IV, sutures to x the gland in its new position at the pectoralis fascia; V, ribs; VI, muscle
M. A. Faria-Correa
Fig. 19.3 Marking shows
externally the breast tissue
to be resected from the
bases of the glandular cone
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Fig. 19.4 Arrow shows
the direction of the
mastopexy toward upper
medial position
Fig. 19.5 Trans-operative
view showing two small
incisions (2cm) at the
submammary sulcus,
through which the shaver
and scope are introduced.
Transcutaneous lifting
sutures are used to
maintain the optical cavity
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Anesthesia andInltration
General, epidural, or local anesthesia can be used. To reduce bleeding, the process
is begun by inltration of epinephrine/saline solution (1:500,000). This is inltrated at the base of the breast in the area to be undermined and inside the
breast tissue.
Incisions
One or two incisions (1–2cm) are made in the submammary sulcus. If necessary,
a third incision can be made at the axilla to help tissue resection or suture
placement.
Traditional open surgery is carried out in three dimensions; however, when
working exclusively with monitor view, the third dimension is lost. This can be
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improved by simultaneously working through two different ports, such that we “triangulate” to a focal point. This provides us with a depth-of-eld feeling in the operative area. The best performance is achieved with a triangulation of approximately
30–45° (Fig.19.5).
M. A. Faria-Correa
Dissection
A retromammary pocket is created between the breast and the pectoralis fascia
(Fig.19.2). This undermining must be wide enough to allow the advancement of the
ptotic gland from the lower lateral to the upper medial position on the chest wall.
This also provides an ample area of internal scarring between the chest wall and the
deep part of the breast tissue. This ample retromammary pocket is created with the
aid of the tomoscope by blunt dissection under endoscopic control. The dissection
area is similar to that where breast implants are placed. The bleeding is controlled
endoscopically by the use of laparoscopic forceps connected to the electrocautery
maneuvering them under monitor view. The dissection of the retromammary pocket
is completed by using laparoscopic scissors connected to the electrocautery. The use
of pressurized gases to create and maintain the work space is avoided. The optical
cavity can be provided with the aid of specially designed, long, and thin elevators
and retractors that are introduced through the work ports. An external lift can be
used by placing sutures through the anterior portion of the cone of the breast
(Fig.19.5).
Breast Tissue Resection
The tissue resection is performed at the base of the gland under endoscopic control,
preserving the anterior cone and glandular ducts. A video arthroscopic shaver can
be used to reduce the breast. The shaver works as a punching aspirator. There are
two cannulas, one rolling inside of the other (Fig.19.6); both are equipped with
windows through which the breast tissue is aspirated and resected. Some breast
glands may be too rigid; therefore, its tissue cannot be resected by this punching
aspirator. Thus, the procedure is performed by the use of a knife, scissors, electrocautery, or laser. This type of breast is the one that is seen on mammography presenting with a large amount of white brous tissue.
By resecting only the base of the breast cone, the functions and sensation are
preserved. This is a physiological mammoplasty. The axillary pole and bottom of
the mammary cone are resected. There is no resection of even small amounts at the
a
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Fig. 19.6 (a) Shaver—a
video arthroscopic
instrument, originally
employed to resect
meniscus and debride
brotic tissue inside the
knee, used to carry out
breast reduction. (b)
Shaver instrument cannula.
There are two cannulas,
one rolling inside the other,
and a punching aspirator
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b
upper pole of the gland. Working endoscopically, the internal breast volume can be
felt externally by hand palpation. By properly planning the tissue resection, the
breast is modeled and sculptured into its new shape.
Breast Lifting Fixation
After obtaining adequate hemostasis, the next step is to lift and x the gland into its
new position (Fig.19.7). Sutures are used to position the mammary gland and x it
to the pectoralis fascia. Suturing can be performed with laparoscopic needle holders. As many sutures as needed are placed to help in positioning the breast so that it
is held in place during the maturation of the internal cicatrix, which ultimately xes
the breast permanently in position. Patients with good skin quality are good candidates for this procedure and gain an aesthetic advantage with the repositioning of
the gland, as this recreates an upper pole to the breast.
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Fig. 19.7 (a, b) Grasping and testing the right position for placing the sutures
M. A. Faria-Correa
Dressings andPostoperative Care
Suction drains are used during the rst 12h and then removed. A micropore tape
dressing (Fig.19.8) helps to reposition the gland in its new site. This dressing is
maintained for 20days for a long-term support. Continuous use of a supporting bra
is recommended for at least 3months thereafter and as long as possible throughout
the patient’s life.
ba
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Fig. 19.8 (a, b) Micropore modulator dressing and drainage
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Complications
Among the 220 cases, 5 cases of hematoma have been observed in patients in whom
no drains were used, and 25 patients had early ptosis recurrence because of poor
skin elasticity.
Discussion
The endoscopic breast reduction and mastopexy techniques preserve the breast
function and sensation with minimal scars (Figs. 19.9 and 19.10) (Faria-Correa
1993, 1994a, b, c, d, e, f, 1995a, c, d, 2000). An important goal is to treat mammary
asymmetry without using prostheses or adding long scars to the breast as opposed
to the traditional procedures.
The breast is an anatomic structure that grows perpendicularly from the chest.
The effects of gravity pull the breast down whether the patient is old or young or
operated on or not. The maintenance of a long-term good result depends not only on
the technique used by the author but also on the skin elasticity for retraction.
Successful long-term follow-up relies on breast weight and precautions taken by the
patient, such as the use of a steadfast modulator bra especially during the practice
of sports.
In patients whose skin does not have the capacity to retract, the results are transitory as in usual mastopexies. Nevertheless, the characteristics of this minimally
invasive technique that have been attracting patients’ interest are the lack of visible
scars and the maintenance of sensitivity and function.
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a
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M. A. Faria-Correa
b
Fig. 19.9 (a1,2) Preoperative 32-year-old patient, who breastfed two children, presenting with
breast ptosis, moderate amount of striae, and moderate degree of abbiness. (b1,2) Eight months
after endoscopic breast lift
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